RITA is dead

I recently had the pleasure of helping with the assessment of the trainees at the annual jamboree that is the Annual Review of Competency Progression, the annual appraisal for trainee doctors in the UK. As a relatively new consultant in Emergency Medicine, I wanted to show willing and maybe help mitigate for any trainees, who like me until recently, had a chronic case of papyrophobia. I kinda figured that, as I was due to start having trainees of my own, working out what they needed to achieve was a sensible place to organise my teaching strategy. It’s also something I felt I should do, on which topic I shall be posting more in the not too distant future.

I have been lucky enough to be raised in the relatively genteel surroundings of the College of Emergency Medicine’s 2007 curriculum. I am assured by colleagues who had the benefits of entering HST prior to the landslide that was Modernising Medical Careers, that training used to be an entirely more civilised affair. You met your trainer formally a few times a year, spent some quality time together on the shop floor, as you were both usually diurnal and hebdomadinary and generally got on with the busyness of emergency medicine. Assessment was a chat over coffee at the Consultant’s meeting and the appropriate forms were forwarded to the deanery, college and General Medical Council. As a disorganised idiot, who had to courier his Clinical Topic Report to the college, after chasing down the chair of the training committee, I really struggled with the minute amount of paperwork associated with the 2007 curriculum. I’d have been completely stuffed with the 2010 curriculum!

The document itself is a monster! My download is 371 pages. There are 7 appendices. I skip read it, along with a lot of other stuff for my Consultant interview and unfortunately forgot all about it as it was SEP. It was a rude awakening at the ARCP. Instead of my poxy 12 WorkBased Placed Assessments, the supplicants candidates had to submit multiple WBPAs, up to 20 annually! That’s going to need a few hours of contact, which proves increasingly difficult in the increasingly anarchic scheduling of ED shifts.

I felt especially sorry for StEmlyns’ own @_nmay. As a senior PEM trainee she had to produce a huge amount of documentation, including WBPAs, certificates and reflective pieces, all carefully mapped to the curriculum. I am a self-confessed geek, but there was a struggle in navigating the e-portfolio. I suspect I would have to have spent an evening a fortnight scanning and linking to keep up with the requirements. If you factor in a glass of wine and a new CD or 2, it doesn’t sound so bad, but let’s not forget that many trainees in EM have young families and, due to the fact that we all work evenings, nights and weekends, may be less keen on spending an odd free evening plugged into a scanner, doing creative writing; certainly I think that Mrs Dr G would have something to say about it on the one night off we shared weekly when I was a registrar!

There are several small glimmers of hope for the more chaotic amongst us. The actual requirement for directly observed care has decreased – there are no more DOPS for example – but there is an increased importance placed on reflection. I have long been a believer that an Emergency Physician is among the most reflective of creatures, even if it’s just over a beer with the team. You figure out what went wrong or right, look at the points of interest, compile a BET, CTR, blog post etc and improve. The other shining light is the “completion of e-learning modules”. I think StE’s ticks that box, as does the college’s own EnlightenMe.

However the increased use of the ACAT, whilst certainly a good tool, means that there has to be increased trainer/trainee face time, which is difficult when EDs get as busy as they seem to. I did one today, with an unusually proactive trainee (I, like most, do my paperwork at the last minute, once having to pester Simon (@EMManchester) for assessments 2 hours before they NEEDED to be in!) and it took an hour. Thankfully for the trainee, there’s multiple links to be made and we also got a CBD for a major presentation out of it!

So what implications does this have for trainees? Apart from the aforementioned night of scanning and linking, you need to be quite creative with the cases that you have seen. You need to record everything and make sure that you have a logbook of patients seen. This is especially important if you are going through unconventional training as it appears to be a requirement. I still think it’s good practice for all trainees it and would be a useful function of any ED’s clinical data system to be able to output numbers, casemix, procedures etc. In the real StE’s , we are redesigning ours and this was a cardinal point that I wanted including, both for the above, but to improve the department’s audit and research.

There also needs to be proactivity in trainees approaching trainers and seniors for credentialling. Given that there needs to be links to the curriculum and for it to be online, the days of hurried form filling 48 hours prior to RITA are gone. The more credentials the merrier as Merda taurorum animas conturbit.

I think also, that the increased amount of evidence needed will make it harder for failing trainees to slip through the net. “Failing to fail” has been acknowledged as a problem in nursing for years; it is not so much a problem in medicine – just look at the numbers censured by the GMC and Nursing and Midwifery Council annually respectively – and all of the EM trainees I have met have been a committed bunch; possibly some of them should have been committed, but that’s a different story! I don’t believe in failing doctors for much apart from gross malpractice and incompetence. Increased assessment and supervision should pick up those struggling, either in performance, knowledge, attitudes or behaviour and allow targeted remedial action.

The implications for me as trainer are the reciprocal of this. I need to actively seek out and spend time with my trainees. I think a couple of hours a week should do it (sorry, in advance, guys, if I haven’t had enough coffee!), but these should be exciting times when I’ll see a patient, they see a patient and we can talk about them and hopefully improve practice together. At the very least, we’ll both get BETs out of the experience and I reckon it’ll make the waiting time in minors better too!

The other implication for me is that I am having to properly read the 2010 curriculum. There’s a hell of a lot in it. However, given that revalidation is nigh, and that this is most likely the standard that we all will be assessed against, it is imperative that we know what our peers consider the standard of our knowledge and practice.

At the end of the day, assessment and paperwork is here to stay. We, whether we like it or not, are in a customer facing organisation and are responsible for the provision of our own quality. Unfortunately, the only measure of this quality is by assessment and appraisal. At least now that everything is online, I need not be so papyrophobic.

p.s. I found out today that yet more, exciting and practical changes are afoot. As these aren’t in the public domain at the moment, I shall have to keep them to myself for now. Needless to say, the CEM have been very perspicacious in their appreciation of the difficulties faced by us all! More on this later, as I expect exciting developments in the next few days…

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Posted by Alan Grayson

Alan Grayson MB ChB, FRCEM is a consultant Emergency Physician in Manchester. He is an honorary senior lecturer at the University of Manchester and associate academic lead for the year 5 MBChB programme. He is Honorary Senior Clinical Lecturer, Centre for Effective Emergency Care, Manchester Metropolitan University

Great news Alan, however, the implications you named are very true not least that in the real virchester/st E we are very busy most of the time and it is very difficult to get just a regular CBD/CEX done let alone finding a trainer able and willing to dedicate an hour or two to trailing you for ACAT assessment. May I just interject here and ask if not seeing the patient then discussing with the consultant for both juniors and may be reg’s (within reason) to review the initial assessment and management and may be that would make final consultant sign off on each patient much easier(a CEM quality marker I believe) and amenable to our practice given that its already been discussed.The said discussion would literally take 5 mins and at least as a consultant you would be secure in the knowledge that the department is under control and from a training perspective each can be a CBD/CEX and at the end of every shift actually like many north American departments trainees could have the whole day signed off so not only do they have a logbook but also effectively an ACAT. I understand that would mean that the consultant would effectively not see patients themselves except for the most important and may be in our real life practice only really attenable on mornings but I feel it would definitely lay the ground work for extension to the rest shift in the future once consultant numbers increase(hopefully) and more importantly given hopefully that the IT system revamp works provide additional data for audit and research of the shop floor. Sorry for the long post just trying to be proactive :-). Thanks again

[…] deanery we have ours. One of these is Calman day. Until this year it was a combination of ARCPs (annual reviews of competency and progression) for the CT3 and ST4-6 trainees in Emergency Medicine […]

[…] the curriculum relevant to each stage of training. Progress in training is assessed annually at the ARCP (Annual Review of Competence Progression) where again a huge amount of time and effort is expended […]

[…] ARCP stands for Annual Review of Competence Progression which all trainees must pass to move onto the next year of training. There are guidelines as to what each grade of trainee must achieve to pass their ARCP. Alan has written about this for St.Emlyn’s a few years ago and you can check this out here. […]